COMMENTARY

Solid Outcomes for Femtosecond Laser Cataract Surgery

New Options Look Bright, Too

Sumit (Sam) Garg, MD

Disclosures

April 11, 2018

Femtosecond Laser Versus Conventional Cataract Surgery

The adoption of femtosecond laser-assisted cataract surgery (FLACS) has remained relatively flat over the past few years. Despite many theoretical benefits, peer-reviewed studies to show superiority compared with conventional cataract surgery are sparse.

Lundström and colleagues[1] evaluated 3379 consecutive FLACS cases. The study participants were all experienced surgeons, removing the confounding factor of a learning curve from their results.

Data were segmented by preoperative corrected distance visual acuity (CDVA). Of note, they found that patients with good preoperative CDVA (Snellen 6/3.8 to 6/6) had fewer complications and better visual and refractive outcomes, whereas those with poor preoperative CDVA (worse than Snellen 6/24) had more complications and poorer visual and refractive outcomes.

Overall, they concluded that FLACS results were favorable in comparison to conventional cataract surgery. There was a correlation of outcomes depending on preoperative CDVA, but outcomes were good among the entire cohort overall.

Viewpoint

The study did have a few shortcomings.

The authors did not report on astigmatic outcomes, and the population was skewed to those who were younger (mean age, 64 years) with no ocular comorbidities. This makes it a little difficult to compare the outcome with many of our more common older patients. Despite this, an impressive number of patients were included, and their reported outcomes were very good with a low rate of vision-threatening complications.

With increasing data to suggest the benefit of FLACS, we are now seeing technologies that provide the benefits of a femtosecond laser but without the same capital investment. Two of these technologies are automated capsulotomy (Zepto®; Mynosys Cellular Devices, Inc, Fremont, California) and nonlaser, nonphaco lens fragmentation (miLOOPTM; Iantech, Reno, Nevada).

However, one challenge remains for US surgeons to embrace these technologies—an avenue for reimbursement. As it stands, we are only able to charge patients for a refractive procedure. The femtosecond laser offers the ability to place corneal astigmatic incisions for which we can charge. The remaining benefits of the femtosecond laser (ie, imaging, femto-fragmentation, and capsulotomy) are included as part of the insurance coverage for the cataract extraction. Likewise, these newer devices provide tangible benefits, but because they are nonrefractive, there is no mechanism for the surgeon or the surgery center to charge for their use. It is my hunch, though, that they will continue to grow in popularity given their clinical benefits.

Additionally, other technologies are being explored, such as Dr Samuel Masket's antidysphotopic intraocular lens, whose design and fixation is dependent on a perfect capsulotomy, which will increase the utility of devices like Zepto.

When considering a femtosecond laser for cataract surgery and devices like Zepto and miLOOP, I believe that there are certain cases where the pros outweigh the cons, even when accounting for the additional cost incurred. The million-dollar question remains whether any of these will become mainstream and supplant the current paradigm of phacoemulsification cataract extraction.

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